>>> CONTINUED OVERLEAF INSIDE THIS ISSUE: > Placental Pathology – An Overview > Cervical Screening – Some Ongoing Misunderstandings ISSUE 4, 2019 If you would prefer to receive the newsletter electronically, please email [email protected]Placental Pathology – An Overview Dr Rachel Maywald - Anatomical Pathologist WHY DO WE DO PLACENTAL PATHOLOGY? Placental pathology is a relatively young field of expertise, having for many years, been considered of low value by most clinicians (including pathologists). However, historically, there was steady rise in OBG indemnity costs after a series of expensive cerebral palsy litigation cases. The 1980s and 1990s saw a rise in both the actual microscopic examination of placentas, and an associated rise in publications. In 2008, Raymond Redline published a series of influential reviews of placental pathology in the context of 158 medico-legal cases, predominantly relating to term gestations complicated by cerebral palsy. These concluded that less that 8% of cerebral palsy at term is “idiopathic”, with 20% association with clinical sentinel events (fetal haemorrhage, sepsis, abruption etc) and 72% associated with placental lesions (severe fetoplacental vascular lesions, chronic changes, subacute to chronic hypoxic changes). Placental pathology has continued to be developed, and with the rise of the ability of pathologists to classify and grade placental lesions in a clinically useful and standardised way, the rate of litigation based on “birth asphyxia” has almost disappeared. I’M A GP, WHY SHOULD I CARE ABOUT THIS PLACENTAL REPORT? Your patient has turned up with a healthy infant for a check- up for themselves or the baby. A placental histopathology report has also turned up, and it shows an abnormality. Mum is healthy, baby is healthy. Do you still care? There are a number of conditions seen in placentas that have a significant risk of recurrence in future pregnancies, and are associated with poor outcomes. Whilst this pregnancy just completed may have had the expected outcome, this may not always be the case, and there is an associated risk in future pregnancies.
Transcript
>>> CONTINUED OVERLEAF
INSIDE THIS ISSUE:> Placental Pathology – An Overview
> Cervical Screening – Some Ongoing Misunderstandings
ISSUE 4, 2019
If you would prefer to receive the newsletter electronically, please email [email protected]
Placental Pathology – An OverviewDr Rachel Maywald - Anatomical Pathologist
WHY DO WE DO PLACENTAL PATHOLOGY?
Placental pathology is a relatively young field of expertise, having for many years, been considered of low value by most clinicians (including pathologists). However, historically, there was steady rise in OBG indemnity costs after a series of expensive cerebral palsy litigation cases. The 1980s and 1990s saw a rise in both the actual microscopic examination of placentas, and an associated rise in publications.
In 2008, Raymond Redline published a series of influential reviews of placental pathology in the context of 158 medico-legal cases, predominantly relating to term gestations complicated by cerebral palsy. These concluded that less that 8% of cerebral palsy at term is “idiopathic”, with 20% association with clinical sentinel events (fetal haemorrhage, sepsis, abruption etc) and 72% associated with placental lesions (severe fetoplacental vascular lesions, chronic changes, subacute to chronic hypoxic changes).
Placental pathology has continued to be developed, and with the rise of the ability of pathologists to classify and grade placental lesions in a clinically useful and standardised way, the rate of litigation based on “birth asphyxia” has almost disappeared.
I’M A GP, WHY SHOULD I CARE ABOUT THIS PLACENTAL REPORT?
Your patient has turned up with a healthy infant for a check-up for themselves or the baby. A placental histopathology report has also turned up, and it shows an abnormality. Mum is healthy, baby is healthy. Do you still care?
There are a number of conditions seen in placentas that have a significant risk of recurrence in future pregnancies, and are associated with poor outcomes. Whilst this pregnancy just completed may have had the expected outcome, this may not always be the case, and there is an associated risk in future pregnancies.
FEATURE ARTICLE
Some findings with a significant recurrence risk include:
infarction)• Villitis of unknown aetiology• Placenta accreta • Severe global/partial maternal malperfusion• Spontaneous preterm birth with histological
chorioamnionitis
Any of these placental findings can be associated with adverse outcomes - whether that be fetal growth restriction, fetal demise, poor neonatal outcomes or poor maternal outcomes. As a result, such patients may warrant closer monitoring / additional scans / more specialised antenatal care in future pregnancies.
There are also diagnostic features that may have more specific management implications apart from monitoring fetal/placental growth. For example, delayed villous maturation should lower the threshold for diabetes screening, have stronger indications for maternal weight management and be an indication for consideration of delivery of a future baby prior to 40 weeks.
Significant fetal vascular malperfusion (especially if there are neonatal sequelae) would prompt a maternal and/or neonatal thrombophilia workup, diabetes scan and maternal platelet evaluation.
Idiopathic / immune lesions such as chronic villitis (of unknown aetiology), massive perivillous fibrin deposition and chronic intervillositis may warrant maternal autoimmune testing, aspirin therapy or low molecular weight therapy, intensive early pregnancy surveillance and/or elective early delivery.
Severe maternal vascular malperfusion warrants evaluation of maternal cardiovascular status, glucose tolerance, thrombophilia and renal function. Aspirin therapy may be indicated.
In addition, early third trimester placental ultrasound /fetal growth assessment and early delivery in subsequent pregnancies would be something that may be considered.
Spontaneous preterm delivery with histological chorioamnionitis may warrant extended neonatal antibiotics, assessment for any underlying periodontal disease or chronic endometritis, and closer assessment of the cervix in second trimester. (vii)
Unfortunately, in some instances, a woman does not come to see you with their baby, as they have had a miscarriage, stillbirth or neonatal demise, or there is a significant neonatal impairment. Do we care more about the placental report?
All the reasons for the interest in a placental abnormality associated with pregnancy apply to a pregnancy with a poor outcome. In addition, the placental examination may explain WHY there was a poor outcome, which is why it is always indicated in such instances. These include evidence of global/partial maternal vascular malperfusion (accelerated maturation), global/partial fetal vascular malperfusion (umbilical cord accident), abruption, fetomaternal haemorrhage, delayed villous maturation, chronic villitis , acute chorioamnionitis with fetal inflammatory response, multiple placental lesions (e.g. infarcts more than 20% of placental volume) etc.
Whilst in many cases a cause for fetal demise or poor fetal outcomes secondary to an identifiable placental is a sporadic event with no risk or very low risk of recurrence (above baseline population risk) - e.g. umbilical cord accidents etc, it is important for the families to know why, if at all possible, there has been a poor fetal outcome.
REFERENCE
Redline, Raymond W. Cerebral Palsy in Term Infants: A Clinicopathologic Analysis of 158 Medicolegal Case Reviews. Pediatric and Developmental Pathology. 2008; 11(6): 456 – 464
Expired THINPREP® Vials
Please ensure that your Thinprep® vials for HPV testing are not expired. There has been an increase of Cervical Screening samples being taken in expired vials. Any expired vials received by TML Pathology will be rejected and the sample will require recollection. All expired vials should be discarded.
FEATURE ARTICLE
Cervical Screening – Some Ongoing MisunderstandingsDr Jason Stone - Head of Cytopathology
The renewed Cervical Screening Program is now just over two years old. Although most General Practitioners and Gynaecologists have made a smooth transition to the new testing method and clinical guidelines, there are still a few recurring problems/misunderstandings. This article will briefly cover a few of these.
CO-TEST (HPV TEST AND CYTOLOGY, REGARDLESS OF THE HPV RESULT)
• A co-test is required for women with clinical symptoms suggestive of cancer i.e. post-menopausal bleeding or recurrent post-coital bleeding.
• Other non-concerning symptoms do NOT require a co-test.
• Patients will get a private fee invoice for any inappropriate testing.
• A co-test is also required as a “Test of Cure” 12 months after treatment of HSIL (CIN2/3) by cervical loop or cone excision. This is for women who have had a histologically proven HSIL (CIN2/3).
FOLLOW UP OF PREVIOUS LSIL OR PREVIOUS POSITIVE HPV TEST
• These cases are followed up with an HPV test only.• Only if this HPV test is positive, will the laboratory arrange
the necessary reflex cytology.
• These cases do NOT require a “co-test”.
• Other vague clinical reasons e.g. “previous abnormality” also do not automatically qualify for a co-test.
• Patients will receive a private fee invoice for the cytology if this is inappropriately requested.
• As described above, a “co-test” is only for symptoms suggestive of cancer or for the Test of Cure in women with treated HSIL.
PREVIOUS AIS
• This tick box on the pathology request form refers to Previous Endocervical Adenocarcinoma in Situ. These specific patients require different testing, different recommendations and different clinical follow-up.
• Please do NOT tick the Previous AIS box if this does not apply to your patient.
• Some GPs are accidentally ticking this box through their practice management software.
• Patients will get a private fee invoice for any inappropriate testing.
ENDOCERVICAL CELLS
• There is no requirement to repeat testing if no endocervical cells are seen.
• The only scenario where this is appropriate is at colposcopy, by a specialist, if the preceding cytology was negative.
• Patients will get a private fee invoice for any inappropriate repeat testing.
RETROSPECTIVE “SYMPTOMS”
• Some GPs are retrospectively informing the laboratory that their patient was “symptomatic”, possibly to avoid the patient getting a private fee invoice for an inappropriate request of cytology. This puts the patient, the GP and the laboratory in a difficult situation for several reasons:
• The National Cancer Screening register needs to be informed of the amended reason for testing
• The Billing needs to be manually reversed
• Medicare needs to be informed of the new reason for test
• Often, the correct testing for a symptomatic patients cannot be done as the sample has been previously disposed of.
• Any new amended report will have the clinical recommendation for referral to a specialist. Not only will the GP now be obliged to act on this recommendation, but the patient will be unnecessarily inconvenienced and may have to pay for unnecessary specialist investigations.
• Obviously, in patients with genuine symptoms that are worrying for cancer, then this is totally the correct course of action to follow.
FURTHER INFORMATION
If you have any questions or require further information, TML Pathology Department of Cytopathology is always happy to help you on (07) 3121 4444.
Thank you to all those who have taken part and continue to take part in our audits we hope that the information offered has been of benefit to your practice and patients.
With only a month to go until the end of the Triennium we are busy finalising points for eligible doctors for the 2017-2019 triennium as well as reviewing feedback, statistics and preparing for the new triennium commencing 1st January 2020. Please check your emails to ensure you have completed and returned evaluations to us; also review your list of activities from 2017 to date with your Colleges to ensure you have all your necessary points including your mandatory Cat 1 QI activity. For any queries regarding events or audits with TML Pathology please do not hesitate to contact us.
The Skin Audit is now closed for the triennium with the final uploads and the award of points occurring at the end of the year. The audit will be reviewed, adjusted based on feedback and will go through the application, adjudication and approval process for RACGP & ACRRM for the 2020 Triennium.
We would like to wish all practitioners and their staff a very safe and happy festive season and we look forward to seeing you all in 2020.
For further information visit tmlpath.com.au or contact your local Medical Liaison Officer. Alternatively, email TML Pathology education at [email protected].
Warm regards, TML Pathology Education
Season’s GreetingsFrom all of us at TML Pathology we wish you and your family a great festive season and a healthy and prosperous 2020.
